Nursing Care, Delirium, and Pain Management for the Hospitalized Older Adult

Original Articles Nursing Care, Delirium, and Pain Management for the Hospitalized Older Adult ---

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Ann M. Schreier, PhD

ABSTRACT:

Delirium is a reversible cognitive disorder that has a rapid onset. Delirium risk factors include older age, severity of illness, poorer baseline functional status, comorbid medical conditions, and dementia. There are adverse consequences of delirium, including increased length of stay and increased mortality. Therefore, it is important for nurses to identify clients at risk and prevent and manage delirium in the hospitalized older client. Once high-risk clients are identified, prevention strategies may be used to reduce the incidence. Examples of prevention strategies include providing glasses and working hearing aids and effective pain management. This article discusses various assessment instruments that detect the presence of delirium. With this information, nurses are better equipped to evaluate the best assessment options for their work setting. Early detection is crucial to reduce the adverse consequences of delirium. Once a client is found to be experiencing delirium, a treatment plan can be established using both nonpharmacologic and pharmacologic interventions. In addition, the identification and the correction of etiologies of delirium can shorten the course of delirium. Ó 2010 by the American Society for Pain Management Nursing

From the East Carolina University College of Nursing. Address correspondence to Ann M. Schreier, PhD, East Carolina University College of Nursing, 3137 Health Sciences Building, Greenville, NC 27858. E-mail: schreieran@ecu. edu Received Jan 2, 2009; Revised July 29, 2009; Accepted July 30, 2009.

1524-9042/$36.00 Ó 2010 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2009.07.002

Delirium is an acute confusion disorder characterized by altered mental status, inattention, disorganized thinking, and altered level of consciousness. With delirium, awareness is reduced and alertness fluctuates between low and high alertness. Typically, disorientation to time and place occur and memory loss (immediate and short-term) occurs. Perceptual disturbances include auditory, visual, and tactile hallucinations and illusions. Either psychomotor agitation or retardation is also part of the delirium syndrome. There are three types of delirium: hyperactive, hypoactive, and mixed. Agitation is a frequent occurrence in hyperactive delirium. Less often recognized is sedation which is characteristic of hypoactive delirium. In hyperactive delirium, patients’ speech may be loud and agitated. In hypoactive, the speech may be retarded and difficult to understand (Arnold, 2005). This disorder is a complex syndrome that results from a disturbance in brain function. In response to multiple physiologic and perceptual alterations, disturbances in neurotransmitters and neurologic pathways in the brain occur (Broadhurst & Wilson, 2001; Flacker & Lipsitz, 1999; Inouye & Ferrucci, 2006; Rigney, 2006). Pain Management Nursing, Vol 11, No 3 (September), 2010: pp 177-185

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In contrast to delirium, the confusion associated with dementia is chronic, slowly progressive, and irreversible. Awareness, attention and alertness are usually not affected. The changes in thinking that occur include difficulty with abstractions and reasoned judgments. Speech is characterized by difficulty in finding words and repetition of words and phrases. Similarly to delirium, hallucinations may occur and sleep can become disturbed. Short-term memory is impaired in both conditions. The patient with dementia may also experience hallucinations (Arnold, 2005).

INCIDENCE There is wide variation in the reported incidence of delirium in acute care settings. These differences are due in part to variations in subject populations and diagnostic criteria for delirium. Vaurio, Sands, Wang, Mullen and Leung (2006) found 46% of post operative patients experience delirium. It can be as high as 61% in postoperative orthopedic patients and in intensive care unit (ICU) it is reported to be as high as 70% (Ely et. al., 2001; Pandharipande, Cotton, Ayumi, Thompson, Pun, Morris, et. al, 2008). There is general agreement that delirium occurs frequently and that the report variation in rates of incidence can be partly due to accuracy in identifying clients experiencing delirium. The fluctuating course of the disorder makes the diagnosis difficult. There are 3 manifestations of delirium: hyperactive; hypoactive and mixed subtype. The hyperactive client exhibiting agitation and restlessness is more likely to be determined to be experiencing delirium. Because of the lethargy experienced in the hypoactive form, health care providers are less likely to recognize the essential features of delirium. In the mixed form of delirium, clients alternate between periods of agitation and lethargy. The incidence of delirium is greatest in post-surgical, orthopedic and intensive care units. Numerous factors including personal characteristics, medical treatment and environment predispose an individual to delirium. Of particular interest to the pain management nurse is the conflicting data on the relationship between opioid administration and delirium. This paper discusses the role of the pain management nurse in the prevention, assessment and management of the client experiencing delirium.

SIGNIFICANCE Leslie, Marcantonio, Zhang, Leo-Summers, and Inoye (2008) estimate that a client with delirium incurs $16,303–$64, 421 in additional hospital costs. Both increased mortality and morbidity are associated with

delirium. Clients who experience delirium in the hospital have longer hospital stays and require more postdischarge services. The altered perception by the delirious patient increases the risk of unsafe behaviors. Therefore, nurses are more likely to use physical and chemical restraints. As a result, adverse physical consequences such as malnutrition, falls, and skin breakdown occur and contribute to the morbidity associated with delirium (Fick & Mion, 2008). In addition to the mortality and morbidity associated with delirium, emotional distress occurs. After recovery from delirium, patients with advanced cancer were able to recall experiencing hallucinations (auditory, tactile, and visual), psychomotor agitation, and disorientation to time and place. Patients and family members rated symptoms distress as 3 on a scale of 0 to 4 (0 indicated no distress) (Breitbart, Gibson, & Trembly 2002; Bruera, et. al., 2009). Miller and Ely (2007) reported that some older patients who experience delirium while hospitalized develop subsequent long-term cognitive dysfunction. Thus, financial, physical, and psychologic costs occur with delirium.

NURSING CARE Assessment of Risk Factors There is no single cause of delirium and in fact, delirium results when multiple predisposing factors and precipitating incidents occur during hospitalization (Foreman, Wakefield, Culp, & Millisen, 2001). Preexisting conditions such as cognitive impairment, sensory losses (hearing, sight), alcohol, tobacco, and drug withdrawal, and age put clients at greater risk. For example, an older person with dementia is at a greatly increased risk for developing delirium. Other factors that may predispose these individuals include illness severity and environment with either too little or too much stimulation (McCusker, Cole, Abrahamoqicz, Han, Podaba, & Ramman-Haddad, 2001). Once admitted to the hospital, certain metabolic alterations can precipitate delirium, including hypoxia, dehydration/electrolyte imbalance, hypoglycemia, nosocomial infection, and multiple medications (Foreman, Wakefield, Culp, & Milisen, 2001; Voyer, Cole, McCusker, St-Jacques, & Laplante, 2008; Waszynski & Petrovic, 2008). In the severely ill hospitalized client, it is not unusual to have multiple predisposing and precipitating factors. Common to all of these precipitating factors is stress. The greater the number of predisposing factors, the more sensitive the patient is to these stressors. Therefore, it is important that these predisposing factors are recognized.

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Prevention of Delirium Although there are multiple predisposing factors, there is currently no quantitative measure of risk. And although not all factors are modifiable, there are nursing interventions that modify the risks. With awareness of predisposing and precipitation factors, prevention strategies have been developed. Research has focused on incorporating these strategies into a standardized protocol for high-risk groups. Because aging is a primary risk factor for delirium, protocols have been developed for older adults. Interdisciplinary teams including geriatric nurse specialists, geriatricians, physical therapists and psychologists are considered to be essential to these prevention protocols (Inouye, van Dyck, Alessi, Balkin, Siegal, & Horwitz, 2000; Marcantonio, Flacker, Wright, & Resnik, 2001; Neitzel, Sendelback, & Larson, 2007). Common elements of the protocols include enhancement of sensory function, environmental manipulation, support of physiologic stability, promotion of physical activity, and pharmacotherapy (Bergmann, Murphy, Kiely, Jones, & Marcantonio, 2005; Foreman, Wakefield, Culp, & Milisen, 2001; Irving & Foreman, 2006; Milisen, Lemiengre, Braes, & Foreman, 2005; Robinson, Rich, Weitzel, Vollmer & Eden, 2008). Environmental manipulations that reduce delirium include noise reduction, changes in light based on time of day, and presence of orienting objects, such as clocks and providing personal possessions (McCusker et. al., 2001). Methods to support physiologic stability included maintaining fluid balance, oxygenation, bowel and bladder function, nutrition and prevention of nosocomial infections (Bergmann Murphy, Kiely, Jones, & Marcantonio, 2005; Foremen, Wakefield, Culp, & Milisen, 2001; Irving & Foreman, 2006; Milisen et. al., 2005; Rigney, 2006). Sleep and orientation are enhanced by physical activity. A decreased incidence of delirium occurs when such protocols are introduced. Table 1 summarizes the risk factors and identifies strategies that may reduce incidence of delirium. Unrelieved Pain and Risk of Delirium Limited information or studies describe the relationship between pain management and delirium. Clearly, the multi-dimensional nature of delirium makes it difficult to study a single etiological factor such as pain and make conclusions and recommendations for effective pain management. Unrelieved pain is one risk factor for delirium. In the presence of severe pain, an individual’s ability to pay attention and to stay on task is severely compromised (Crombez, Eccleston, Baeyens & Eelen, 1996; Eccleston & Crobez, 1999). Hearing loss is another frequently reported risk factor for delirium. Unrelieved pain and hearing loss may have an interactive effect on cognitive function. Patients with hearing

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loss are likely to receive lower doses of pain medication and more likely to experience delirium (Robinson, Rich, Weitzel, Vollmer, & Eden, 2008). This finding suggests that lack of effective communication may result in poorer assessment and management of pain in the hearing-impaired older adult. Therefore, nurses should be aware of hearing losses and use strategies such as hearing aids to improve communication. Nurses should face clients and speak clearly and in a normal voice. Researchers have studied the relationship between postoperative pain, pain management, and delirium. Hospitalized adults after hip fracture who received less effective pain management were more likely to experience delirium (Milsen, Lemiengre, Braes, & Foreman, 2005; Morrison et. al., 2003). Increased postoperative pain increased the risk of delirium (Lynch, Lazor, Gellis, Orav, Goldman, & Goldman, 1998; Vaurio, Sands, Wang, Mullen, & Leung, 2006). Postoperative patients who received greater amounts of pain medication had a delayed onset of delirium (Robinson, Rich, Weitzel, Vollmer, & Eden, 2008). When long-term care patients were admitted to an acute care hospital, those who received opioids were more likely to experience mild delirium than moderate to severe delirium (Voyer, McCusker, Cole, St-Jacques, & Khomenko, 2007). These studies suggest that effective pain management reduces the risk for delirium and that nurses should implement effective individualized pain management strategies with clients at risk for or experiencing delirium.

Pharmacologic Treatment of Pain and Risk of Delirium Other research has focused on whether the type of pain medication has an effect on delirium. Studies comparing morphine and fentanyl, morphine and hydrocodone, and morphine and tramadol demonstrated no significant difference between these medications and the development of delirium (Herrick, Ganapathy, Komar, Moote, Dobkowski, & Eliasziw, 1996; Rapp, Egan, Ross, Wild, Terman, & Ching, 1996; Silvasti, Svartling, Pitkanen, & Rosenberg, 2000). In one study, Morita, Takigawa, Onishi, Tajima, Tani, Matsubara, Miyoshi, Ikenaga, Akechi, and Uchimoto (2005) found that the rotation of morphine to fentanyl in delirium cancer patients reduced the severity of delirium. Pandharipande, Shintani, Peterson, Truman, Wilkinson, et al. (2008) found that morphine was associated with a decreased risk of delirium and fentanyl to an increased risk in ICUs. Patients receiving meperidine experienced delirium at a greater rate (Fong, Sands, & Leung, 2006; Morrison et al., 2003). These studies suggest that changing the type of opioid has little effect on

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TABLE 1. Delirium Risk Factors in the Older Adult and Prevention Strategies Physiologic Characteristic

Evidence for [ Risk

Age Oxygenation

Older age Y O2 saturation

Fluid balance Circulation

Dehydration Electrolyte imbalance Hypoperfusion

Temperature

[

Substance use

Withdrawal from alcohol, tobacco, or other substances

Pain

Unrelieved pain

Cognition

Dementia

Sensation

Hearing and vision losses

Mobility

Y

Polypharmacy

Drug interactions

delirium incidence. Moreover, adequate administration of opioids for pain is likely to decrease delirium risk. Assessment Measures It is challenging for nurses to distinguish between mental status changes associated with delirium and those associated with dementia. When reviewing nursing documentation, Voyer, Cole, McCusker, St-Jacques, and Laplante (2008) found that nurses often used the vague term ‘‘confused’’ to describe mental status changes and cognitive deficits. The term ‘‘confused’’ is not specific to the delirium because ‘‘confused’’ is also a characteristic of dementia. Dementia is a progressive cognitive disorder characterized by memory loss with impaired executive function. As stated previously, delirium and dementia share some symptoms. For older adults, a screening test of cognitive function on admission allows the nurse to determine if the patient

Prevention Strategy More frequent assessment Monitor oxygen saturation closely, apply oxygen when indicated Monitor BUN, creatinine, sodium, glucose I & O Provide access to oral fluids and/or provide IV fluids Monitor BP and HR Provide appropriate medical interventions Monitor temperature in patients with infections Provide measures to reduce temperature Assess prehospital use of substances Monitor for withdrawal symptoms Formulate a plan; possible use of nicotine patches; medications to manage withdrawal symptom Schedule round-the-clock pain medication administration Assess for effectiveness of pain management protocol Avoid use of meperidine and propoxphene hydrochloride Assess usual routine including ADL, food likes, sleep habits and incorporate whenever possible Provide reassurance by speaking calmly and informing patient about all activities planned before implementation (e.g., vital sign measurements) Provide consistent nursing staff Provide memory cues Involve family in care Limit number of room changes Provide assistive devices, and alert staff to losses Provide nightlights Use music Reduce television use and extraneous noise Provide ambulation and range of motion Limit use of indwelling urinary catheters Review medications for necessity, and consider alternative symptom management

may have dementia. There are two instruments that are available to assess for dementia. An abbreviated cognition assessment (Mini-COG) can be performed to assess dementia characteristics (Doerflinger, 2007). The Mini-COG is a simple 3-item instrument and has a sensitivity of 76% and a specificity of 89% (Borson, Scanlan, Chen, & Ganguli, 2003). Alternatively, the Brief Evaluation of Executive Function can be used to assess the older client for signs of dementia (Kennedy & Symth, 2008). The Brief Evaluation of Executive Function is composed of three tests: Royall’s Clox Drawing, Controlled Oral Word Association, and the oral version of the Trail Making test (Kennedy & Symth, 2008). Both of these instruments are available through the Hartford Institute for Geriatric Nursing website: www.consultgerirn.com. If the findings are positive, the patient should be referred for diagnosis. Dementia severity can also be measured using the Hierarchic

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Dementia Scale but likely has minimal clinical usefulness (Hadjistavropoulos, Voyer, Sharpe, Verreault, & Aubin, 2008). Family caregivers can provide the nurse with valuable information that can assist in determining if the patient has dementia (Arnold, 2005). To distinguish between delirium and dementia, the nurse can question the family members about the client’s usual functioning before hospitalization. Does the patient normally have difficulty with memory? Does the person forget how to get home? Does s/he have difficulty with remembering how to do familiar tasks? If the nurse determines that cognitive function is impaired, then more frequent assessments for delirium are indicated. Some authors report that nurses lack a sufficient understanding of delirium symptoms and therefore delirium remains underdiagnosed (Foreman, Wakefield, Culp, & Milisen, 2001; Lemiengre, Nelis, Joosten, Braes, Foreman, Gastmans, & Milisen, 2006; Voyer, Cole, McCusker, St-Jacques, & Laplante, 2008). A lack of understanding and use of assessment instrumentation reduces definitive care of the delirious older adult. Therefore, the use of assessment tools is vital to effective care of older adults. Currently, there are three evidence-based delirium instruments in use. The Confusion Assessment Method (CAM) and the Neelon and Champagne Confusion Scale (NEECHAM) detect the presence of delirium (Inouye, van Dyck, Alessi, Balkin, Siegal, & Horwitz, 1990; Neelon, Champagne, Carlson, & Funk, 1996, Rapp, Wakefield, Kundrat, Mentes, Tripp-Reimer, Culp, Mobly, Akins, & Onega, 2000). The Delirium Index (DI) is a measure of severity of delirium (McCusker, Cole, Dendukuri, & Belzile, 2004). The CAM was based on the Diagnostic and Statistical Manual of Mental Disorders DSM-IV diagnostic criteria (American Psychiatric Association, 2000). The following elements of mental status are captured by the CAM: level of consciousness, orientation, attention or concentration, recall impairment, language, onset of symptoms, variability of symptoms, perceptual disturbances, sleep-wake disturbance, and changes in psychomotor behavior. The patient is diagnosed with delirium when the nurse identifies that the patient has an acute onset and exhibits inattention as well as either disoriented thinking or disorientation. In a systematic review of literature from 1991 to 2006, the CAM instrument was cited in 239 articles. The instrument demonstrated a sensitivity of 94% and a specificity of 89% (Wei, Fearing, Sternberg, & Inouye, 2008). The CAM has been used in a variety of settings, including long-term care. Wei, Fearing, Sternberg, and Inouye (2008) emphasized that education is necessary for the most

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accurate detection of delirium. Nurses can be educated by using web-based material (Try This Series, 2008). However, routine use of the CAM is hampered by various hospitals’ documentation systems. Several factors must be in place for nurses’ routine use of CAM. First, the CAM needs to be a part of routine nursing documentation. Second, nursing management must identify delirium assessment as a priority and provide the specified education (30 minutes). Third, nurses must consistently use the CAM. Using these principles, Waszynski and Petrovic (2008) successfully implemented the CAM into routine documentation on two nursing units. The Neelon-Champaigne Confusion Assessment Scale (NEECHAM) is designed specifically for nurses to assess the risk of confusion through bedside observation. The instrument includes all of the elements of the CAM (cognitive and behavioral components) as well as physiologic measures (appearance, vital sign stability, oxygen saturation, and urinary continence) (Neelon, Champagne, Carlson, & Funk, 1996). These variables of physical function distinguish it from the other instruments that measure delirium. Neelon et al. (1996) report alpha coefficient of .90 and interrater reliability of .90. Fewer nurse researchers report using the NEECHAM. Neitzel, Sendelbach, and Larson (2007) found that incorporating the scale into the electronic medical record was difficult and that during their pilot study nurses used the scale for only 13% of the patients on the orthopedic unit studied. The DI is a measure of symptom severity based on the CAM. Patients are rated by health care provider observation of 0 symptoms to 3 severe symptoms on seven of the CAM domains (McCusker, Cole, Dendukuri, & Belzile, 2004). The DI includes the Mini Mental Status Examination, and these questions are used to determine the severity of symptoms. The severity measure may be useful in the evaluation of effectiveness of treatment measures. Treatment for Delirium Once delirium has occurred, the major focus of nursing care is to keep the patient safe. Some authors suggest that early recognition of delirium enhances the resolution of the condition (Rigney, 2006; Puntillo, 2007). Bergmann, Murphy, Kiely, Jones, and Marcantonio (2005) developed a standardized protocol for the treatment of delirium in a postacute nursing facility. With this protocol, once a patient was identified to be experiencing delirium, further assessment and treatment was initiated. The plan included identification and treatment of possible causes, prevention and management of complications of delirium, and restoration of function. Consistency in nursing staff is

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recommended (Neville, 2006). Other suggested strategies include repeated reorientation of the client, listening to music, removing catheters and IV lines as soon as possible, refraining from use of restraints, careful management of medications, scheduled pain medications, minimizing unnecessary noise and stimuli, and early ambulation (Neville, 2006; Puntillo, 2007; Rigney, 2006; Robinson, Rich, Weizel, Vollmer, & Eden, 2008). Personal interaction is important in assuring the patient’s safety when delirium occurs. Specific knowledge and skill is necessary for the effective treatment of delirium. Many authors recommend the use of a clinical nurse specialist or gerontology consultations. With the reported lack of knowledge among nursing staff, nursing specialists can educate staff on the current best practices (Foreman et. al., 2001; Lemiengre et al., 2006; Voyer et. al., 2008). Family members and educated volunteers can assist with the reorientation and vigilance needed to assure the safety of the person with delirium. It is also important that the care partners (nursing assistants) are knowledgeable about delirium prevention and treatment (Milisen et al., 2005). An interdisciplinary team supports quality care for the delirious patient. Pharmacologic treatment of the older adult is complicated, because of alterations in metabolism and excretion of medications. Pharmacologic treatment is considered to be a last resort in the management of agitation associated with delirium (Irving & Forman, 2006; Puntillo, 2007). Pun and Dunn (2007) recommend following the Society of Critical Care Medical guidelines and use antipsychotic haloperidol to manage the agitation. Both lorazepam and midozolam are independent risk factors for delirium in intensive care unit patients, and therefore, benzodiazepines are contraindicated in the treatment of delirium (Pandharipande, Shintani, Peterson, Pun, Wilkinson, Dittus, Bernard, & Ely, 2006). When considering the possible adverse consequences of medications, nonpharmacologic options are less risky to use in treating delirium.

CASE STUDY The following case study illustrates principals of evidenced-based care of an older adult experiencing delirium. Mrs. Emily Jones is an 89-year-old woman who is admitted to the hospital for pneumonia. Mrs. Jones lives alone in her home. She requires some assistance with activities of daily living. She receives ‘‘Meals on Wheels’’ 5 days a week and has a home health aide who assists her 3 days a week. She has a daughter who lives nearby and assists her on weekends as well as visits her on the 2 days a week when the home

health aide does not come. Mrs. Jones’ daughter accompanied her to the hospital. On admission, the nursing assessment reveals the following data: vital signs: temperature 38.8 C, pulse 70/min and regular, respirations 24/min and shallow, blood pressure 140/68 mm Hg; lung sounds: course diffuse wheezing through lung fields; productive cough with thick yellow sputum; oxygen saturation 90% on room air; skin turgor poor; bowel sounds hyperactive in all quadrants; complaint of several loose stools before admission; pain on inspiration of 5 (0-10 scale); and sensory: no hearing loss, wears glasses. Mrs. Jones has a past medical history of congestive heart failure (CHF) and hypertension. Her usual oral medications for CHF include digoxin 0.125 mg every day, hydrochlorathiazide 25 mg per day, and potassium chloride 20 mEq per day. Before admission, her family nurse practitioner prescribed azithromycin 500 mg for first day and then 250 mg per day for 4 days. The nurse performs CAM and finds that Mrs. Jones exhibits difficulty maintaining attention, with disorganized thinking and hyperalertness. The nurse asks the daughter to describe her mother’s usual cognitive state. She states, ‘‘mother is clear as a bell, she is always coherent and is normally very calm.’’ From these data, the nurse draws the following conclusions: Mrs. Jones is experiencing hyperactive delirium (acute confusion disorder) as evidenced by acute onset of her hyperalertness, difficulty maintaining attention, and disorganized thinking. In addition, the nurse recognizes that the following factors have likely contributed to Mrs. Jones’ delirium: elevated temperature, dehydration, diminished oxygenation with ineffective airway clearance, and unrelieved pain. The hospitalist ordered Oxygen 2L via nasal cannula, IV fluids (D5 1/2 NS at 75 mL/hour), acetaminophen 650 mg every 4 hours PRN for temperature >38 C., cepharin sodium 500 mg every 6 hours IV piggyback and oxycodone hydrochloride 5-10 mg every 6 hours PRN for pain. The nurse places priority on administering acetaminophen (650 mg) and oxycodone (5 mg) and beginning IV fluids. In addition, the nurse applies the oxygen and uses pulse oximetry to monitor O2 saturations. Intake and output are monitored. These actions are intended to treat the possible contributing causes of delirium. The following plan of care is instituted to manage delirium: Reassure and explain to the daughter about the cognitive changes; enlist her aid to reorient Mrs. Jones and that her presence is therapeutic, use the dry-erase board in her room to communicate the date and the names of the staff caring for her. In addition, the nurse communicates to the staff that Mrs. Jones is experiencing delirium and directs all staff to introduce themselves each time they enter the room and

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reorient Mrs. Jones’ to time and place. The nurse assures that Mrs. Jones wears her glasses and that they are clean. The nurse plans to initially assess Mrs. Jones’ mental status using CAM each hour. Recognizing that safety is a priority for the patient experiencing delirium, the nurse ensures that the bed is kept in low position and locked, only two side rails are used, the bed alarm is activated, the call bell is in reach, the daughter is instructed to let staff know when she is leaving, and Mrs. Jones’ is offered toileting every 2 hours. If Mrs. Jones is able, she is assisted to ambulate to the bathroom. The daughter is taught how to assist Mrs. Jones with range of motion exercises. In addition, the environment is managed with reduced clutter and appropriate lighting. When Mrs. Jones’ temperature and pain are decreased, the nurse notes that her mental status improves. The plan of care is continued throughout the hospitalization.

RECOMMENDATIONS In acute care, delirium is a frequently occurring phenomenon. There is an association between unrelieved pain and the occurrence of delirium. The pain management nurse plays an important role in educating colleagues and advocating for evidence-based care of older adults. Staff nurses are not always knowledgeable about the prevention and management of delirium. Research evidence has shown that delirium can be prevented, and there is a need for these preventions to

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become part of standard practice. Pain management nurses are in a position to provide leadership in translating research into practice. At the unit level, nurses can advocate for prevention strategies, including effective pain management. These nurses can heighten the awareness of the importance of assessing for delirium routinely with older adults. Through staff dialogue, nurses can strategize on how to incorporate the elements of CAM in the institution’s documentation. In addition, nurses skilled in care of the older adult can advocate with all members of the health care team to manage delirium through nonpharmacologic methods.

CONCLUSIONS By promoting best practices, nurses may effectively reduce the incidence of delirium. These practices include careful attention to fluid status, judicious pain control, maintaining appropriate sensory perception by providing assistive devices (glasses and hearing aids), and providing an environment conducive to maintaining mental status. When nurses consistently assess for delirium by using an evidence-based tool such as CAM, early identification occurs before symptoms become severe. The nurse can then institute evidence-based interventions. Because of the fluctuating course of delirium, it is difficult to assess the effectiveness of these interventions. However, future research may lead to increasing the body of knowledge of this complex condition.

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